Table Of ContentDiagnostic
Clusters in Shoulder
Conditions
Puneet Monga
Lennard Funk
Editors
123
Diagnostic Clusters in Shoulder Conditions
Puneet Monga • Lennard Funk
Editors
Diagnostic Clusters in
Shoulder Conditions
Editors
Puneet Monga Lennard Funk
Upper Limb Unit Upper Limb Unit
Wrightington Hospital Wrightington Hospital
WN6 9EP WN6 9EP
Lancashire Lancashire
United Kingdom United Kingdom
ISBN 978-3-319-57332-8 ISBN 978-3-319-57334-2 (eBook)
DOI 10.1007/978-3-319-57334-2
Library of Congress Control Number: 2017953774
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Dedicated to Archita, my better half, and to
the two best daughters in the world, Arushi
and Anika, for their innumerable sacrifices.
–Puneet
With thanks to my wife and children—my joy,
my support and my sanity.
–Lennard
Rationale of Diagnostic Clusters
An accurate diagnosis is the foundation of Good Medical Practice.
The inspiration for this work has been to pull together the diagnostic knowledge,
skills, and wisdom gathered over generations by the orthopaedic fraternity practis-
ing common sense orthopaedics. The relevance and need of such common
sense-based clinical practice has been amplified by the pressures faced by the
chaotic Internet information boom, easy access to radiology, corporatization of
medical care, and the rapid pace of our life demanding binary answers to complex
questions.
In routine clinical practice, the diagnosis of a particular shoulder condition is
best made on history, clinical examination, and special tests, usually with the help
of radiological investigations. It is often the case that all these subcomponents are to
be used in conjunction with each other as “clusters” rather than in isolation. Current
textbooks are focused on physical examination techniques or radiological examina-
tion and do not take into account this cluster approach one needs to use in everyday
practice. The purpose of this book is to bridge this gap and serve as a practical guide
to diagnosis in modern day clinical practice.
We are all familiar with the patients who have had a scan which shows a “tear,”
and having done their Internet research, they present with an expectation for such a
“tear," often in the absence of relevant clinical symptoms, to be “fixed.” This book
is to serve as a reminder that a clinical diagnosis remains reliant on multiple sources.
This reminder is particularly relevant in the current vastness of medical information
available on the Internet for patients and clinicians alike. This work represents a
body of collective experience and knowledge of carefully selected shoulder sur-
geons and specialist physiotherapists, who practice the cluster approach to making
a diagnosis.
A focused history can tease out the diagnosis in a vast number of shoulder condi-
tions. Also, the conventional examination of the shoulder joint follows a sequence
of “look, feel, and move.” This sequence is in line with the orthopaedic examination
of other joints. The knowledge of shoulder conditions has vastly improved over the
past two decades, with the “shoulder subspecialty” growing at a rapid pace regard-
ing practitioner numbers, knowledge, evidence base, and procedures. One has seen
vii
viii Rationale of Diagnostic Clusters
the emergence of a vast variety of “special tests” to aid in the diagnosis of shoulder
conditions. In conditions such as subacromial impingement, for example, over 12
special tests have been described. The multitude of special tests means that the clini-
cian faces a vast choice of tests, with a broad range of sensitivities and specificities.
At the same time, radiological techniques have advanced rapidly over the last
decade with significant leaps in quality, speed, and indications. Such developments
are so rapid that the clinical implications of radiological findings are frequently
debated!
Hence, the four key pillars over which one constructs a diagnosis are a clinical
history, the conventional examination sequence, special tests, and radiological
investigations. Diagnosis of a particular condition relies on a varying degree of sup-
port from these individual pillars. The first section of the book defines these four key
pillars. Each of these initial chapters describes the particular Pillar and provides a
broad knowledge over which the subsequent chapters are then constructed. The reli-
ability of a diagnosis is high when individual subcomponents are aligned. Equally,
when different subcomponents are not overlapping and pointing in the same direc-
tion, the confidence in the diagnosis is lower. One needs to accept that the outcome
of diagnostic assessment may well be a “probable diagnosis” which needs further
clarification by invasive techniques such as arthroscopy (Fig. 1).
Pain, weakness, and instability are the three common reasons for which patients
seek help for their shoulders. Further sections of the book have been structured
around these three presentations rather than pathological processes. The book is a
step in the direction of patient-centred medical literature and will serve to remind us
to think about “what’s the patient in clinic for?” Within these sections, specific con-
ditions with their corresponding “clusters” comprise the bulk of the work. The
authors have painstakingly extracted the relevant components from clinical experi-
ence, published work, clinical examination textbooks, radiology textbooks, and
online resources.
This work is based out of the Wrightington Hospital, which provided a setting for
the pioneering work of our forebear Late Sir John Charnley, the father of modern
Hip Replacement. He continues to provide us with an unending source of inspira-
tion. We are honoured to have the blessings of Dr. Ben Kibler for this work, who
History Examination
History Examination
History
Examination
Special Tests
Investigations
Special
Tests Investigations Special Investigations
Tests
Precise Diagnosis Probable Diagnosis Unlikely diagnosis
Fig. 1 Reliability of a diagnosis
Rationale of Diagnostic Clusters ix
challenged us to think about “what’s relevant to the patient” throughout the prepara-
tion of this book. There is no doubt that you would notice a streak of common sense
orthopaedics across each chapter, a tribute to the lessons learnt from Mr. Tim
Meadows, retired Consultant Orthopaedic Surgeon, and also to our surgical trainers
spread across the globe. We are grateful to the great support from the publishers,
Springer, and in particular Liz Pope, Priya Vairamani and Andre Tournois in the
editorial team.
The overall proposed style of writing for the book is a practical, well-referenced,
easy-to-read resource for general practitioners, orthopaedic trainees, physiothera-
pists, orthopaedic surgeons, radiology trainees, radiographers, and musculoskeletal
radiologists. As with all works addressing the complexity of diagnostic decisions,
the knowledge is vast and fast evolving. We accept that any book of this nature can-
not claim to be a comprehensive guide and we would welcome feedback from the
readers. Each chapter starts with an illustrative case example signifying a “classic”
patient presentation, the detailed description of individual diagnostic clusters, and
finally a discussion of the case and a chapter summary with a tabulated summary of
clusters. Subcomponents of clusters have been chosen based on evidence, experi-
ence, and applicability. Such a subdivision is designed for a quick read-through for
a busy clinician, if they so wish.
We hope you enjoy reading this book as much as we have enjoyed compiling and
editing “The Shoulder Clusters.”
2017 Puneet Monga
Lennard Funk
Prologue: Making the Diagnosis
I am honoured to be asked to write a prologue for this book on diagnosis in shoulder
disorders. Any book needs a strong rationale and definite application to be relevant.
This book is relevant. It addresses an important topic at a timely point in the evolu-
tion of our knowledge of the treatment of shoulder injuries. It highlights the funda-
mental importance of the diagnosis in treatment, a point which is frequently
undervalued or underappreciated.
The diagnosis is the key and critical aspect in health care. All treatment interven-
tions are based on the information provided in the diagnosis. The diagnosis should
be able to answer the question “why is the patient in your office,” both from the
patient’s and the doctor’s point of view. Most patients report they come to the office
to be evaluated and treated for an alteration in their functional capability [1], while
most doctors report they feel the patient has come to be assessed for a particular
alteration of anatomy. The comprehensive diagnostic process can help the clinician
assemble all relevant information necessary to address the functional problem. An
effective diagnosis can be defined as “that body of information, collected through
the process of evaluating the patient’s health problem, that determines the content
and timing of the treatment of the health problem”[2]. The diagnostic process may
be short or long, may involve several steps, or may require outside consultation, but
the goal is to produce a more precise and complete understanding of the patient’s
health problem.
In the USA, the Institute of Medicine (IOM), now named the National Academy
of Medicine (NAM), has recognised the central importance of the diagnosis in
health care and the problems associated with inefficient diagnoses. In September
2015, the IOM produced the latest report in its highly regarded Quality Chasm
Series, titled “Improving diagnosis in health care” [2]. The report documented trou-
bling deficiencies in the effectiveness of developing the diagnosis in all health care
disciplines. They called these deficiencies “diagnostic errors.” Diagnostic errors
may be defined as “the failure to develop the information required to establish an
accurate and timely explanation of the patient’s health problem, and the failure to
meaningfully communicate the information to the patient” [2]. The information
must be accurate (not differing from the actual patient problem, or imprecise or
xi
xii Prologue: Making the Diagnosis
INFO&R MINATTEIORNPR INETTAETGIORNATION
Has sufficieCnt liinnfiocramlation been collected?
Patient Patient History and Physical
EaP xrHopebelareilemthnces EHSnyesgatalethgm eCsa wreith GATHINEFORRINMAGTION CRoenfIensrutrealtralv atiieonwnd DTEeixasagtminngostic WORDKIIANGGNOSIS Tttthhohea Cote thfoh ieetsmeh x apecpmlao tlDahutmin eniapmanicgrttouainobntoniloiesc noimasftedTcdaiharege n pTbolraaesnsaisentmde deo nnpt aththe of PSLdneieayaaastgitrrene nOnmomitnus i sagtiOscsn f oeudreomstrcm,r eooasmrnsd,es
accurate, timely
diagnosis
TIME
Fig. 2 The Diagnostic process as presented by Balough et al. (2015)
incomplete) and timely (not delaying the correct treatment). It also must be com-
municated to the patient in understandable terms so the patient can participate in the
determination of the treatment plan. Diagnostic errors can be harmful in several
ways. They can prevent or delay appropriate treatment, they can lead to inappropri-
ate or unnecessary treatment, and/or they increase medical expenditures and waste
financial and medical resources.
In addition to documenting the presence and incidence of diagnostic errors, the
report described a general model of the diagnostic process that was designed to
systematically address the components of the diagnostic process, in order to bring a
more unified approach to the process (Fig. 2) [2].
The general suggestions made in the IOM report have specific application for
orthopaedics and shoulder surgery. There are multiple studies in the orthopaedic
literature that support the report’s conclusions regarding the imprecision and lack of
effectiveness of the diagnosis for shoulder injuries [3–11]. Also, the general model
described in the IOM report for the diagnostic process can be used as a framework
for re-envisioning the process in orthopaedics. The model is very similar to the
rationale for diagnostic clusters that forms the basis for this book. Several points can
be made regarding the applicability of the model to orthopaedics and shoulder sur-
gery, and for use in applying the principles advocated in this book. First, it is sequen-
tial, starting with the patient experiencing some alteration of their normal functional
status. In this book, the main alterations are pain, weakness, and instability, but
there may be others that need to be elucidated by interaction with the patient.
Second, it emphasises the key role for comprehensive information gathering from
multiple sources, a point emphasised strongly in this book in the four key pillars. I
would add two other supporting resources: (1) including patient-determined factors
and expectations, such as the apprehension of the injury and treatment and problems
with job status, and (2) information from arthroscopic or other surgical observations
